Indirect Communications and a Rare Situation Need Special Attention

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. . . .”

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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 two 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 one 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.

In a letter three days later to Dr. P from a university newborn screening program confirming metabolic screening for the baby, the program coordinator went on to state that since the initial hemoglobin pattern after a transfusion is not interpretable, optional follow-up testing is available through the program. The letter explained that “1 cc of whole blood is required to do white blood cell DNA analysis to determine the presence/absence of hemoglobinopathies. Please let me know if you would like to complete this follow-up testing. There is no charge to complete this test.” Enclosed with the letter was a pamphlet titled “Why Does My Baby Need More Testing for Metabolic Diseases?” Another handout, titled “FAQs about Newborn Screening and Transfusion Follow-Up,” explained that after a transfusion of packed red blood cells, the hemoglobin test pattern is not valid because the donor’s blood cells mask the hemoglobin results for the newborn. A fax cover sheet included a question about whether Dr. P was interested in following up on the transfusion matter.

At the one-week follow-up visit by the parents and baby, Dr. P’s examination and review of the baby’s development were all normal. Carnitine labs delivered the next day were mostly normal and by one week later, carnitine tests were all within normal limits.

At the baby’s one-month visit, Dr. P noted the patient’s history of possible carnitine deficiency and his examination showed a normal baby. A few days later, Dr. P received a fax advising him that the physician overseeing the carnitine issue had resolved the case as having no screenable metabolic condition.

Later that month, however, while being fed by her mother, the baby started coughing, turned blue, and stopped breathing. At the ER, the baby was noted to have pancytopenia with a white blood count of 1.1, hemoglobin of 1.5, and platelets of 7. She received packed red blood cells during transport to a specialized hospital, but intervention there failed to improve on her “incredibly poor prognosis.” The baby died after the decision was made to remove her from CPR.

A subsequent lawsuit by the baby’s parents alleged that given his knowledge of the intrauterine transfusions for anemia following alloimmunization, Dr. P should have referred the baby to a specialist or monitored the patient himself for signs of anemia requiring treatment. Dr. P resolved the lawsuit informally.

The record shows Dr. P aggressively addressing the patient’s bilirubin issues and carefully monitoring her carnitine course. But they also show no targeted inquiry into hemoglobin patterns after discharge or investigation into the risks alloimmunization may have had on the baby’s ability to produce healthy blood.

Granted, the patient’s history presented a very rare set of circumstances for Dr. P and no one chose to call him to talk through the anemia issues directly. The documented warnings on suspect hemoglobin patterns and the written invitations for assistance, however, would likely have had a strong influence on a jury.   

Gordon Ownby is CAP’s General Counsel. Questions or comments related to “Case of the Month” should be directed to gownby@CAPphysicians.com.