Some communications among a patient's healthcare team may not be as direct as one would prefer, but they may still trigger a duty on the recipient to follow up.
Dr P, a general pediatrician, was called to attend a vaginal delivery of a newborn with a history of three fetal transfusion surgeries. Dr P ordered for his newborn patient a transcutaneous bilirubin test, and when that test revealed hyperbilirubinemia, Dr P ordered phototherapy.
An initial screening report from the California Department of Public Health Newborn Screening Program on blood collected at 25 hours included results consistent with carnitine transporter deficiency. As to hemoglobin, however, the report noted that "because of transfusion, no interpretation is possible" and that "further testing on whole blood is recommended to rule out hemoglobinopathies. Call your Newborn Screening Coordinator for assistance..."
The fetus had started receiving the transfusions at 29 weeks for moderate to severe anemia secondary to Rh(D) and Rh(C) alloimmunization. Under the care of a fetal surgery specialist associated with a regional maternal fetal health institute, the fetal hemoglobin was 6.9 prior to the first transfusion, converting to 14.2 post transfusion.
Two further transfusions showed changes from 8.4 to 15.1 and from 8.7 to 15.9. The specialist recommended that a neonatology team be prepared for an immediate transfusion at delivery. No transfusion was noted in the records, though the umbilical cord was milked to give the baby as much blood as possible.
A hemogram drawn at 2 days of age showed hemoglobin of 16.7 and hematocrit of 46.6. That report, however, included no warning on transfusion issues. Though the in utero blood transfusions had been noted in the baby's admission history as a risk factor, Dr P's discharge did not address anemia follow-up. The discharge documentation carried the hemogram values from the baby's second day.
At the baby's office visit the next day, Dr P noted that his patient had received intrauterine blood transfusions and had been jaundiced at the hospital. His physical exam of the patient that day was normal, as was the parents' report on their child's activity. Dr P noted the possible carnitine transporter issue and advised the parents to return in 1 week, or sooner if the baby showed a change in behavior. Dr P also noted the need for the baby to see a metabolic geneticist for additional testing. Bilirubin tests ordered that day came back normal.
© 2020 Cooperative of American Physicians, Inc.
This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories.