Driving the Yellow Bus

We're happy to offer the first post from Flea--a guest blogger who's also pediatrician in the northeast. You can  check out his drfleablog,  here.

A pediatrician shouldn’t be writing about medical malpractice. We fleas don’t get sued very often. Our malpractice insurance premiums are a fraction of what our colleagues on OB/GYN pay. Parents like us. We wear cute ties and nice fuzzy animals on our stethoscopes.

But pediatricians and other fleas do get sued. If a bad outcome occurs in a hospital, the hospital may get sued as well. Hospitals don’t like to be sued. They will do anything legally and reasonably in their power to prevent medical malpractice suits.

A few years ago, a baby born at a hospital in my community died of a rare condition known as kernicterus. It seems the baby had a very high level of a substance called bilirubin in his blood. Bilirubin is the yellow pigment that gives rise to the yellow skin condition known as jaundice. In high enough concentrations, bilirubin can be toxic to brains and can even cause death. The hospital settled for an undisclosed, but presumed very large amount of money.

A few months later, the hospital decided to implement a universal bilirubin screening protocol. In other words, every baby born at the hospital would have a bilirubin test, regardless of how yellow the baby appeared. The chairman of the department of Pediatrics confided in me that the main reason for the policy was to prevent any more damaging medical malpractice suits.

In the course of the next several months, neighboring hospitals developed their own universal bilirubin screening processes. As a result, cases of bilirubin toxicity have declined, but at a cost of delayed discharges, unnecessary phototherapy, and costly testing for the majority of healthy newborns that need no such testing.

The champion of bilirubin protocols, Vinod Bhutani, has advocated universal screening since 1998. The American Academy of Pediatrics has recommended that hospitals create neonatal hyperbilirubinemia protocols, but has not recommended universal bilirubin screening per se.

The energy behind implementation of universal bilirubin screening derives from fear of litigation, as was the case at my local hospital. There is no question in my mind that defensive medicine as opposed to medical common sense is driving the (yellow) bus here.

Comments

[Clark Bartram]

Regardless of the hospital's intention, it is not necessarily poor form to implement such screening protocols. Kernicterus, although not common, has increased in incidence despite our current efforts and it is a devestating condition. One way to solve this issue is with the use of transcutaneous bilirubin meters. These have been shown to be fairly accurate. One study showed in around 400 children that they were never off by more than 3. Check every baby and if the addition of 3 to the cutaneous level would change your managment get a venous level. Much fewer sticks, better screening than the "looks kind of yellow" protocol.

[Dr John Crippen]

Hi Flea

thanks for dragging me over to this fascinating site.

Now, a question. Immunisations. Which we have been covering.

Have there been any cases yet (I say yet, because it is the USA and I bet there will me) of children who, at the insistence of their parents, have NOT been immunised according to recommendations and then gone on to contract measles or whatever, suing their parents for neglect?

John

[Flea]

Not to my knowledge, John. But there have been dumber, more outrageous suits filed here, the litany of which would be hilarious if it weren't all so damned serious.

best,

Flea