Missed meningitis

tallaght01

I know it's almost 3 months out of date, but somebody just showed me this story....

http://news.bbc.co.uk/2/hi/uk_news/scotland/south_of_scotland/7153737.stm

A judge has awarded nearly £140,000 in damages to the children of a woman who died from meningitis a day after being seen at an out-of-hours surgery.
Catherine Learmont, 37, died on 26 December 1999 after being told she had a viral infection and sent home.

In his judgment Lord Uist said Dr Fiona Vernon's consultation in Dumfries was "short, cursory and superficial".

At the Court of Session in Edinburgh he ruled her handling of the case had been professionally negligent.

Ms Learmont's daughter Lauren and son Scott raised an action for damages against the doctor claiming their mother's death was caused or contributed to by the general practitioner's fault and negligence.



Dr Vernon contested liability.

The court heard that Ms Learmont began to feel unwell on Christmas Eve and felt worse the following morning.

In the afternoon she saw Dr Vernon at an out-of-hours surgery in Dumfries before going home.

Her daughter Lauren, of Lorimer Crescent, Dumfries, told the court that she had gone to check on her mother on Boxing Day.

"That's when I found my mum - my mum was dead," she said.

"There was only my mum looked after me.

"We didn't see our dad - my mum was like my mum and dad."


Dr Vernon was ruled to have been professionally negligent

Ms Learmont's cause of death was later established as acute bacterial meningitis.

Lord Uist said in his judgment: "Dr Vernon ought to have suspected meningitis, prescribed an antibiotic blind and referred Ms Learmont to the nearby Dumfries and Galloway Royal Infirmary, in which event Mrs Learmont would have survived.

"As Dr Vernon did not refer Ms Learmont, she was professionally negligent."

Lord Uist said Ms Learmont had been a "bright, attractive" woman who was divorced and lived with her son, then aged 17, and her daughter, then aged 14, at the family home.

He said that having considered all the relevant evidence he had come to the view that the doctor was "not an entirely credible and reliable witness in relation to events at the consultation".

Potential emergency

"I gained the clear impression from the evidence that Dr Vernon from the outset approached her dealings with Ms Learmont with a certain attitude, which was that there was nothing seriously wrong with her, other than possibly a viral infection," he said.

The patient was told in a phone call prior to the consultation that she was "quite happy to have a wee look at you" but "be prepared to wait, we'll see you when we can".

The judge said: "The last statement seems to me to indicate that she did not consider Ms Learmont's case was a potential medical emergency and that she should be assessed urgently."

Lord Uist said that after hearing evidence in the case he had concluded that the consultation between the GP and patient lasted about five minutes.

He said: "I have reached the conclusion that the consultation which she had with Ms Learmont was short, cursory and superficial."

Pretty awful case for all concerned.

I've underlined and bolded the bits that I thought were strange in the ruling.

But I wonder how fair it is for the judge to rule on the doc's ability to spot meningitis over the phone!

I've also said stuff like that to people.

There but for the grace of god, I guess......

It certainly brings back some not-nice memories of the time I missed a case of meningitis in a baby. Didn't sleep for about 2 weeks afterwards, even though, in hindsight, I wasn't at fault.

I remember aswell, when I was a surgical intern we were referred a lady who had abdo pain. The surgical SHO rang me and told me I could send her home. There was some confusion, whereby we both thought the other had checked her abdo x-ray. Neither of us had. We realised this about an hour later, and looked at it.

There was air under the diaphragm! Perforated ulcer. I rang them at home, and her husband said she was getting worse. So we had her rushed back in for emergency surgery.

Funnily enough, they were extremely understanding. I admitted the mistake to them immediately. I expected there to be hell. But she and her husband said they were so impresed that i went to them and admitted my mistake straight away, that they weren't annoyed.

She even said "oh you young doctors are under so much pressure, you're bound to miss a few things now and again".

What a nice lady. They used to write to me periodically in the hospital, too, updating me on her recovery!

Anyway, I'm rambling now.%

Chunky Monkey

Shouldn't it have been the SHO's responsibilty as a doctor more senior than you to make absolutely sure the film was checked so technically their mistake not yours?

On Cardiac Arrest there was an episode where a girl came into A+E with flu like symptoms and was sent home. Her parents brought her in later that same day and she had a stiff neck, rash and wasnt able to see into the light (didn't have any of those earlier). She died not long after. Does that sort of thing happen in real life? Is doing a lumbar puncture the only way of telling if someone has meningitis if they don't have the other signs they told us about in the ads? Does meningitis always look like the flu initially or is there a whole other range of symptoms too?

Sorry about all the questions, I really can't wait to start med school and start learning about these things

kelle

That's so shocking. But I understand meningitis can be difficult to spot in the early stages. What do you do - refer everybody with flu-like symptoms to A&E and lead to overcrowding?
My friend was concerned her 2-week-old son was constipated, his cry had weakened and his fingers felt stiff. She made an appointment with her GP. Doctor didn't examine baby, just looked at back passage and gave advise on treating constipation, and sent them home.
2 days later, baby was no better, she returned to GP. Luckily, there was a locum GP working that day. She examined baby thoroughly, then said there was something going on she wasn't quite happy with, so advised my friend to bring baby straightaway to the hospital where he was born (an hour's drive). She arrived there, there was a team of doctors waiting for her, took the baby and immediately administered triple antibiotic and then he was rushed by ambulance to Temple Street.
Very, very dramatic (I can't imagine what my poor friend went through!). Thankfully, baby was okay and is now a livewire 4-year-old.
It was never discovered whether he got meningitis or septicemia, but he had 2 lumbar punctures and each one was stained with blood so they couldn't be examined.
It's difficult to know if the GP was genuinely negligent, would the symptoms have been as obvious had the baby had as thorough an examination on the first visit? We'll never know.

tallaght01

Chunky Monkey wrote: »

Shouldn't it have been the SHO's responsibilty as a doctor more senior than you to make absolutely sure the film was checked so technically their mistake not yours?

On Cardiac Arrest there was an episode where a girl came into A+E with flu like symptoms and was sent home. Her parents brought her in later that same day and she had a stiff neck, rash and wasnt able to see into the light (didn't have any of those earlier). She died not long after. Does that sort of thing happen in real life? Is doing a lumbar puncture the only way of telling if someone has meningitis if they don't have the other signs they told us about in the ads? Does meningitis always look like the flu initially or is there a whole other range of symptoms too?

Sorry about all the questions, I really can't wait to start med school and start learning about these things

Med school is indeed an exciting time

If someone comes in with suspected meningitis, you should do a lumbar puncture. It's the gold standard for diagnosing it. You look at the cells in the fluid, to see if the white cell count etc is suggestive of meningitis, or if there are bugs there under the microscope. Then it gets sent off for culture and PCR.

Sometimes you can't do an LP, as the patient has signs of increased intracranial pressure. If you do an LP on one of these patients, their brain can literally get sucked into their spinal column.

So, usually, a patient rocks in. You suspect meningitis. You do a blood culture, a urinalysis/culture, a chest xray and a lumbar puncture, to see if there's a source of infection elsewhere.

One you've done those things, you start the antibiotics. Then you wait for the cultures to arrive back. You may change your antibiotics depending on whether the patient seems to be improving or not in the meantime (cultures take up to 48 hours, sometimes even longer), and what bug is grown in the cultures.

If the patient comes in very unwell, you usually leave the LP until they're more stable, and take blood cultures and a cxr straight away, and get IV fluids and IV antibiotics into them straight away.

There are other variations to this theme, where you factor in herpes encephalitis, people who need inotropes etc, but that's another day's work :P

As for your question about what happened in cardiac arrest, LOTS of the kids I see with meningitis and/or sepsis will have been diagnosed by their GP as viral illness. Sometimes serious illness is masked for ages beforehand. It's very easily missed.

Always remember young kids don't always get classic signs of meningitis, and a high white cell count/high CRP in the abscence of another focus for infection warrants an LP in many cases. Below 3 months, all kids with a fever that's not obviously emanating from anywhere else needs an LP, IV antibiotics and at leat 2 days in hospital. Most kids up to 6 months are the same.

High temps in very young people should be treated as very serious if there's no obvious source.

Traumadoc

I have been very suprised at some of the patients I have had with meningitis, some are remarkably well, I had one recently who had a slight rash and a temperature, slight headache but nothing florid, Lucikly we commenced him on Antibiotics, Lumbar puncture confirmed Meningocccal.

Chunky Monkey

Thanks for the detailed reply Would meningitis occur more often in kids?

beeno67

Traumadoc wrote: »

I have been very suprised at some of the patients I have had with meningitis, some are remarkably well, I had one recently who had a slight rash and a temperature, slight headache but nothing florid, Lucikly we commenced him on Antibiotics, Lumbar puncture confirmed Meningocccal.

Couldn't agree more. I had one a few years ago (as a GP), twelve year old brought to surgery by mother complaining of headache for a few days. No temp, no neck stiffness, no vomiting, no rash, looked remarkably well. I was happy to send home. Mother said she was very worried. Purely to keep mother happy I referred in to hospital and asked them to keep overnight. SHO thought it was a total dump. Long story short had lumbar puncture next day. Meningococcal meningitis.

tallaght01

Chunky Monkey wrote: »

Thanks for the detailed reply Would meningitis occur more often in kids?

Depends on the type, but by and large yes.

We also treat a lot more kids for meningitis and sepsis in particular, who don't actually have it, than the big-people-doctors do.

Infectious diseases is very much our bread and butter in paeds.

sronoc

I went to GP before with vomiting, stiff neck, joint and muscle pain, headache, photo phobia and a red rash that covered my body that started to turn into purple lumps on my hands

I pointed out that the rash didnt disappear under pressure of a glass.

I said I thought it was meningitis and asked for a test

GP had a quick look and sent me home for bed rest, said he thought it was a bad case of flu.

To cut long story short, 12 hours after my visit to GP I was found unconscious in my bed

Ended up on life support for 3 days and in hospital for 2 weeks.

If I knew then what I know now I'd have sued him for negligence.

Vorsprung

sronoc wrote: »

I went to GP before with vomiting, stiff neck, joint and muscle pain, headache, photo phobia and a red rash that covered my body that started to turn into purple lumps on my hands

I pointed out that the rash didnt disappear under pressure of a glass.

I said I thought it was meningitis and asked for a test

GP had a quick look and sent me home for bed rest, said he thought it was a bad case of flu.

That sounds particularly dodgy

gordon_gekko

bigjimthefirst wrote: »

That sounds particularly dodgy

you made the fatal mistake of having an opinion in front of a doctor

his only option to show he disagreed was to dismiss your concerns and send you home

i know all about doctors downplaying conditions

there main concern is there ego , not peoples recovery

hunnymonster

gordon_gekko wrote: »

you made the fatal mistake of having an opinion in front of a doctor

his only option to show he disagreed was to dismiss your concerns and send you home

i know all about doctors downplaying conditions

there main concern is there ego , not peoples recovery

I have to say, that hasn't been my experience at all. Almost every medical doctor I've seen has listened to my opinions. Without wanting to sound like a hypochondriac or nomad, I've seen a lot of doctors in a lot of hospitals and ractices, and with only one exception they have all listened carefully to what I had to say. On occasions when they didn't agree with my opinions, they always had the science to back it up.

The only exception was a SpR I saw in A&E 3 weeks ago who refused to believe that a swollen ankle was not normal for me after running 80 miles. You can't really blame him either but his refusal to listen has resulted in a lot of pain and further treatment.

gordon_gekko

hunnymonster wrote: »

I have to say, that hasn't been my experience at all. Almost every medical doctor I've seen has listened to my opinions. Without wanting to sound like a hypochondriac or nomad, I've seen a lot of doctors in a lot of hospitals and ractices, and with only one exception they have all listened carefully to what I had to say. On occasions when they didn't agree with my opinions, they always had the science to back it up.

The only exception was a SpR I saw in A&E 3 weeks ago who refused to believe that a swollen ankle was not normal for me after running 80 miles. You can't really blame him either but his refusal to listen has resulted in a lot of pain and further treatment.

doctors listen to x ray or other test results , not people, they also dole out pills just to shut you up

helimachoptor

tallaght01 wrote: »

Sometimes you can't do an LP, as the patient has signs of increased intracranial pressure. If you do an LP on one of these patients, their brain can literally get sucked into their spinal column.

Please tell me your joking?

charlieroot

Its true, though I think the medical jargon for it is - you're brain stem will become herniated

Traumadoc

Actually, its coning.

charlieroot

Traumadoc wrote: »

Actually, its coning.

I stand corrected! Thanks.

Fantasy_Suicide

EDIT: Sorry, I ment to start a new thread

SomeDose

tallaght01 wrote: »

Depends on the type, but by and large yes.

We also treat a lot more kids for meningitis and sepsis in particular, who don't actually have it, than the big-people-doctors do.

Infectious diseases is very much our bread and butter in paeds.

This thread bump got me thinking...what's the current consensus regarding fluid management of paediatric cases? Back when I did a stint in paeds I recall one of the PICU docs saying that there's some disagreement as to whether fluid resus is appropriate or not, and it was also highlighted in a recent Clinical Pharmacist journal article. Apparantly the argument against it was to do with SIADH and potentially exacerbating cerebral oedema, thereby worsening outcomes.

What's the latest line of thinking?

tallaght01

SomeDose wrote: »

This thread bump got me thinking...what's the current consensus regarding fluid management of paediatric cases? Back when I did a stint in paeds I recall one of the PICU docs saying that there's some disagreement as to whether fluid resus is appropriate or not, and it was also highlighted in a recent Clinical Pharmacist journal article. Apparantly the argument against it was to do with SIADH and potentially exacerbating cerebral oedema, thereby worsening outcomes.

What's the latest line of thinking?

basically, you have to fluid resuscitate as required. So, if they've volume depleted, you need to give a fluid bolus. But thereafter most people are fluid restricting all kids with intracranial or intrathoracic infections, for SIADH reasons. Often as low as 50% of maintenance fluids. The little ones in particular drop their sodium levels very easily.

locum-motion

tallaght01 wrote: »

Med school is indeed an exciting time

If someone comes in with suspected meningitis, you should do a lumbar puncture. It's the gold standard for diagnosing it. You look at the cells in the fluid, to see if the white cell count etc is suggestive of meningitis, or if there are bugs there under the microscope. Then it gets sent off for culture and PCR.

Sometimes you can't do an LP, as the patient has signs of increased intracranial pressure. If you do an LP on one of these patients, their brain can literally get sucked into their spinal column.

So, usually, a patient rocks in. You suspect meningitis. You do a blood culture, a urinalysis/culture, a chest xray and a lumbar puncture, to see if there's a source of infection elsewhere.

One you've done those things, you start the antibiotics. Then you wait for the cultures to arrive back. You may change your antibiotics depending on whether the patient seems to be improving or not in the meantime (cultures take up to 48 hours, sometimes even longer), and what bug is grown in the cultures.

If the patient comes in very unwell, you usually leave the LP until they're more stable, and take blood cultures and a cxr straight away, and get IV fluids and IV antibiotics into them straight away.

There are other variations to this theme, where you factor in herpes encephalitis, people who need inotropes etc, but that's another day's work :P

As for your question about what happened in cardiac arrest, LOTS of the kids I see with meningitis and/or sepsis will have been diagnosed by their GP as viral illness. Sometimes serious illness is masked for ages beforehand. It's very easily missed.

Always remember young kids don't always get classic signs of meningitis, and a high white cell count/high CRP in the abscence of another focus for infection warrants an LP in many cases. Below 3 months, all kids with a fever that's not obviously emanating from anywhere else needs an LP, IV antibiotics and at leat 2 days in hospital. Most kids up to 6 months are the same.

High temps in very young people should be treated as very serious if there's no obvious source.

What about th'oul rash that doesn't fade under a glass? You didn't mention that.
As a community pharmacist, I've always reckoned that that would be the most likely symptom I'd see at the counter (hasn't happened yet, thankfully). Apart from that and the headache with stiff neck, what else should be a warning sign for me to refer?

nesf

tallaght01 wrote: »

High temps in very young people should be treated as very serious if there's no obvious source.

What's a high temp? 40+? (seems like a useful thing for a parent to know)

AmcD

I don't refer patients to A+E much. But after a few recent experiences I am beginning to wonder how some of the A+E SHOs got so confident?
1. A 4yr old boy came in with his mother. He was lethargic and unwell. He was a rarity in general practice- a very sick child that needs hospital. We undressed him and I found one petechia. I rang for an ambulance and said I needed an urgent one for suspected menigococcal meningitis. It was a friday evening. On monday morning I rang his mother to see how he was. She said that he had been assessed in A+E after arriving by ambulance. He was then sent home (?!). She rang an ambulance herself the next night when he woke up screaming, covered in a pupuric rash. Luckily he spent only 24 hrs in ICU before getting completely back to normal.
2. I sent in a middle-aged woman to A+E with the worst headache of her life which had suddenly "floored" her. She said she felt as if she was going to die. She had other features which made me suspect a sub-arachnoid haemorrhage. She was formally told that she had a "severe headache" by the A+E officer who discharged her.

When I was in A+E I was conscious of not dumping referrals on the teams on call and I knew there was pressure to keep things on an outpatient basis. Am I overestimating the importance of a referral letter? Are they even read?

nesf

AmcD wrote: »

I don't refer patients to A+E much. But after a few recent experiences I am beginning to wonder how some of the A+E SHOs got so confident?
1. A 4yr old boy came in with his mother. He was lethargic and unwell. He was a rarity in general practice- a very sick child that needs hospital. We undressed him and I found one petechia. I rang for an ambulance and said I needed an urgent one for suspected menigococcal meningitis. It was a friday evening. On monday morning I rang his mother to see how he was. She said that he had been assessed in A+E after arriving by ambulance. He was then sent home (?!). She rang an ambulance herself the next night when he woke up screaming, covered in a pupuric rash. Luckily he spent only 24 hrs in ICU before getting completely back to normal.
2. I sent in a middle-aged woman to A+E with the worst headache of her life which had suddenly "floored" her. She said she felt as if she was going to die. She had other features which made me suspect a sub-arachnoid haemorrhage. She was formally told that she had a "severe headache" by the A+E officer who discharged her.

When I was in A+E I was conscious of not dumping referrals on the teams on call and I knew there was pressure to keep things on an outpatient basis. Am I overestimating the importance of a referral letter? Are they even read?

One thing that would strike me is that A&E staff have no experience with the patient and don't know what they're normally like. Someone telling them they've a severe headache is quite different to someone who you know doesn't complain of severe headaches coming into you to look for help with one.

For instance, with my GP she's paranoid about my chest because over and over again we've seen an ear/sinus/throat infection that was being treated with an antibiotic turning into a much worse chest infection with potential for pluerisy etc (I've also had pneumonia). If I present to a new GP with an ENT infection then they'll probably (and correctly) give me an antibiotic and not give it a second thought.

tallaght01

AmcD wrote: »

I don't refer patients to A+E much. But after a few recent experiences I am beginning to wonder how some of the A+E SHOs got so confident?
1. A 4yr old boy came in with his mother. He was lethargic and unwell. He was a rarity in general practice- a very sick child that needs hospital. We undressed him and I found one petechia. I rang for an ambulance and said I needed an urgent one for suspected menigococcal meningitis. It was a friday evening. On monday morning I rang his mother to see how he was. She said that he had been assessed in A+E after arriving by ambulance. He was then sent home (?!). She rang an ambulance herself the next night when he woke up screaming, covered in a pupuric rash. Luckily he spent only 24 hrs in ICU before getting completely back to normal.

We get a few of these sent up every so often, and the most common reason for them being discharged is because the petechiae are either isolated and don't progress, or are in the distriution of the SVC in a vomiting child. In all these cases, though, you'd be doing an FBC.

You should keep referring them, as they do need a period of observation. But a kiddy with vomiting and petechie in the SVC distribution is unlikely to get a diagnosis of meningitis.

I don't know where you saw the spot. But it does happen a lot. The other pointer for a straightforward virus is a bounce-back with some paracetamol. It's very common to get a kiddy like this sent up, who responde really well after some panadol. Those kids are very unlikely to score an LP.

I like a good referral letter. It's a big difference working in Oz. In the UK I'd always get a good letter from the GP, and very often a phonecall. In the Oz, I'll usually get 2 lines of "This kid is sick. ? meningitic. No previous med Hx. Would be grateful for your opinion".

MrCreosote

It's hard to say much from the report and judges comment. I've worked in NZ since 2002 and there is a large number of meningococcal disease cases there, waning a little bit now.

When I got there first any adult under 30 with an undifferentiated fever over 38.5 got a LP. Loads of kiddies sent in too with one or two petechiae- 95% had some virus but a good number had meningococcal disease. All of them got one shot of ceftriaxone while the PCR and cultures were in the lab.
And lots were hard to spot- that was the thing that stuck out for me. Sure some are really obviously unwell, but most of them didn't look bad at all.

And as for referral letters- a good one makes a big difference I think. Now I'm the one writing them I usually go for the "Sick, please assess, thanx" scrawled on a loose sheet of paper though...

nesf

MrCreosote wrote: »

Now I'm the one writing them I usually go for the "Sick, please assess, thanx" scrawled on a loose sheet of paper though...

Next time you get an obviously severely sick patient, do the referral note in crayon.

AmcD

I am thinking of writing "admit" on a post-it and sticking it to the next patient I send to A+E.

Seriously though, when I was working in Crumlin in the A+E, the one thing that impressed me was the triage nurses. They seem to have a sixth sense for meningococcal disease. If you saw them carrying out a child ringed in biro, then you got worried.
The only thing I can think of that can possibly explain why my meningococcal boy got sent home, is that maybe he had a miraculous reaction to a dose of paralink that I sprang on him.

MrCreosote

nesf wrote: »

Next time you get an obviously severely sick patient, do the referral note in crayon.

Good idea. I can save time by holding it fist-style as well.

It's part of GP training- you spend at least a week learning how to best annoy the Emergency docs...

nesf

MrCreosote wrote: »

Good idea. I can save time by holding it fist-style as well.

It's part of GP training- you spend at least a week learning how to best annoy the Emergency docs...

I've this wonderful mental image of a person with pneumonia, a temp of 43 and unable to breathe fully due to pleurisy weakly pushing forward a crumpled piece of paper with a picture drawn in crayon on it with stick figures representing doctors and so on...

Amnesiac_ie

My personal experience is that communication between the Emergency Department and General Practitioners is really poor in Ireland and particularly so in Dublin. Of course there are exceptions to this generalisation (I'd like to consider myself as one!) but the norm is for poor or a complete lack of communication between GPs and the ED staff.

It's an area I would really like to see addressed properly as I think improving the two way flow of information between primary care and and the ED would reduce waiting times, cut out a lot of unnecessary tests and greatly benefit the ongoing care of patients, particularly those with chronic illness.

Australian GPs appear to share a common IT system with their local hospitals which helps but in Ireland I think local hospitals and referring GPs should work on local solutions.

I'm largely removed from ED and primary care in my current line of work but it's an area someone interested in getting on a GP training scheme could well do some intersting audit/research...

locum-motion

MrCreosote wrote: »

It's part of GP training- you spend at least a week learning how to best annoy the Emergency docs...

Is that before or after they teach you how to write illegibly to annoy the community pharmacists?

MrCreosote

locum-motion wrote: »

Is that before or after they teach you how to write illegibly to annoy the community pharmacists?

It used to be easy. But computerised notes and printers have meant more advanced techniques have to be employed, like running down the printer ink, or scrawling changes on the script after it's printed out. My own favourite is to get the script hot off the printer and drag it along the desk to smear the ink.

If it wasn't for us the pharmacists would have too much time on their hands, and be causing all sorts of industrial strife...

locum-motion

MrCreosote wrote: »

It used to be easy. But computerised notes and printers have meant more advanced techniques have to be employed, like running down the printer ink, or scrawling changes on the script after it's printed out. My own favourite is to get the script hot off the printer and drag it along the desk to smear the ink.

If it wasn't for us the pharmacists would have too much time on their hands, and be causing all sorts of industrial strife...

Haven't come across your favourite one (yet...I'll keep my eyes open for it!) Doesn't that get ink all over your desk, though?
L-M.
ps. Sometimes I feel like ringing up the surgery and asking them to change the ink ribbon. Haven't done it yet, though. Would prefer not to pi55 you all off too much!