A disagreement over a diagnosis

What should you do if you do not agree with your partner's diagnosis of meningitis?

THE DILEMMA

During surgery, I was interrupted by my younger partner asking me to take out benzyl penicillin injectable urgently from my emergency bag.

She said that a 13-month-old child lying on her couch has a meningococcal rash and would I help by administering penicillin urgently while she contacted the emergency paediatric team.

The child looked well. There was a tiny spotty macular rash on the legs with a blueish tinge to it which my partner said did not blanche on pressure.

The mother had tears in her eyes. My partner said that she thought it was meningitis but early administration and rapid admission would give the best possible prognosis.

Our reception staff was dialling 999 and calling the local paediatric receiving team. I had not made a full assessment, but on my superficial viewing I was doubtful of the diagnosis.

Should I let the process go ahead, and maybe let the child have unnecessary trauma, or worry the mother and risk my partner's ire by stating that injection and admission are not needed?

A GP'S VIEW - DR LOUISE WARBURTON, A GP IN IRONBRIDGE, SHROPSHIRE

This situation requires tactful handling. It might harm my partner's confidence if I appear to undermine her clinical acumen in front of a patient.

However, it may also be harmful to the patient's mother if the child is rushed unnecessarily to hospital.

There is no substitute for careful assessment. I would ask my partner to clarify the clinical details while I had a careful look at the rash. It can be very difficult to spot a meningococcal rash in its early stages.

I would also ascertain quickly, and tactfully, from my partner if she had any previous experience of dealing with meningococcal septicaemia.

She may have had a case in the past or she may have had a bad experience which is influencing her judgment in this case.

If I am still convinced that the rash is not meningococcal, I would have to say this to my partner and the patient's mother.

I might still think that the child needs assessment and requires hospital admission, and would ask the parents to take the child there instead.

Rushing the child to hospital by ambulance would be traumatic for everyone if unnecessary.

Obviously, I would try and get my partner to understand my reasoning and allow her to be involved in this change so that she does not lose face.

A PATIENT'S VIEW - TREVOR SEEMANN, PATIENT PARTNERSHIP GROUP

The problem of diagnosis is paramount. Having requested your assistance your partner has given you the right to have a medical opinion. If you have any doubts you have a duty to interject.

It would not seem unreasonable for you to make a thorough examination of the child. I would also ask your partner to reassure the mother that while she may suspect meningitis it is not a foregone conclusion.

Unless you are certain that it is not meningitis, and assuming no overt adverse effects from such injections, I would proceed with the penicillin injection.

If you are certain that it is not meningitis then you must not proceed despite anyone's protestations.

I am also concerned about the conduct of your partner. Knowing she needed assistance, why did she not take the opportunity to ask you for a second opinion? You could have then discussed the case professionally as a team, made a joint diagnosis, reassured the mother and treated the child appropriately.

Your partner must be made aware that you are there as her professional friend and that she must be more compassionate with parents' feelings.

If your practice discusses these matters together you can set up protocols that will improve its quality assurance for professionals and patients.

A MEDICO-LEGAL VIEW - DR GRAHAM HOWARTH, MEDICO-LEGAL ADVISER AT THE MPS

Your obligations are to the child and mother here. Not humiliating your partner and not compromising yourself medico-legally are merely for consideration.

Missing meningitis does not necessarily equate to negligence as long as your approach would be supported by a reasonable body of your peers under similar circumstances.

However, if you are wrong here, and your colleague had already diagnosed meningitis it is unlikely that you would be able to offer a reasonable argument that your skills complied with those of your peers.

Also, remember that the classic symptoms and signs of meningitis are of late onset and that their diagnostic accuracy is far from perfect.

Additionally, untreated meningitis has a poor prognosis and initial treatment greatly improves outcome and usually has a low morbidity.

You must act in the child and mother's best interest, and if you are convinced that the child does not have meningitis then stop the process in the way least likely to humiliate your partner. Alternatively, and probably more practically, if there is any doubt in your mind then manage in accordance with your partner's diagnosis, while reassuring the mother.

Once the emergency is over ensure that your partner's emergency bag contains the appropriate medication. Any outstanding concerns you may have are best addressed later.

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