Malpractice Counsel: Child abuse, methadone overdose

Missed Child Abuse

A 7-year-old girl was brought to the ED by her mother for discomfort with urination. The patient was otherwise healthy, up-to-date on all of her immunizations, and without any other complaints. Her vital signs were normal, and the physical examination was unremarkable. Although the chart did not reflect that a genitourinary examination was performed, the emergency physician (EP) stated that he had performed one.

A urinalysis was obtained, which was consistent with a bacterial infection. The patient was diagnosed with a urinary tract infection (UTI), prescribed an antibiotic, and discharged home with appropriate instructions.

Approximately 11 months later, it was discovered that the patient and her older sister were victims of sexual abuse by their 17-year-old stepbrother. Apparently, the abuse had started several months prior to the patient’s ED visit. The mother sued the EP and hospital for failure to recognize the signs and symptoms of sexual abuse. The plaintiff argued the child and mother should have been questioned about the possibility of sexual abuse, and that a more detailed physical examination would have shown evidence of abuse. The defense argued that the child’s presentation did not suggest sexual abuse; a defense verdict was returned.

Discussion

There are no reliable estimates of the incidence of pediatric sexual abuse in the United States. According to the most recent US Department of Health and Human Services Child Maltreatment Report, approximately 62,936 cases of child sexual abuse were reported in the United States in 2012, representing 9.3% of the total number of reported maltreatment cases that year.¹ A meta-analysis of 22 US-based studies using national, local, and regional sampling found a much higher rate. This data suggest that 30% to 40% of girls and 13% of boys experienced sexual abuse during childhood.²

For EPs, sexually abused pediatric patients usually present in one of two ways: they are presented by a caregiver based on a suspicion or a disclosure of sexual abuse; or, in the more difficult presentation, they are brought in for evaluation of symptoms related to the genitourinary system or rectum. Such symptoms include vaginal discharge or anal or vaginal bleeding, and the presence of a sexually transmitted infection or UTI. While UTI is frequently listed as a potential sign of sexual abuse in children, there are no good data to demonstrate its frequency. Compounding this problem is that approximately 3% of girls and 1% of boys in the general population are diagnosed with a UTI prior to the onset of puberty.³ Interestingly, though most texts and articles discussing pediatric sexual abuse usually include UTI as a potential sign of abuse, reviews of UTIs in pediatric patients seldom include a discussion of sexual abuse as a potential etiology.

Emergency physicians must therefore maintain a high index of suspicion when evaluating a pediatric patient with a genitourinary or rectal complaint. If the child is old enough to give a history, the caregiver(s) should be asked to leave the room and the patient questioned directly about improper touching, physical activity, etc. The genital and perianal areas should be visually inspected. In general, a speculum examination is not necessary unless vaginal penetration is suspected or the patient is an older adolescent. The majority of pediatric patients can simply be examined in the supine, frog-leg position.

Physical signs of penetration include the presence of concavities (hymen notches), especially at the 6 o’clock position. In addition, irregularities in the hymen contour may be associated with prior injury. More obvious signs of sexual abuse include the presence of warts (condyloma acuminata or lata), vesicles, ulcers, bruising, or vaginal discharge.⁴ It is important to remember that the absence of physical findings does not exclude sexual abuse.

Laboratory testing of suspected victims of sexual abuse should include cultures of the vagina and rectum for gonorrhea and chlamydia, and throat cultures for gonorrhea.⁴ Additional testing should be based on the history and physical examination.

When an EP suspects child abuse, he or she must contact child protective services and/or law enforcement agencies, as required by law. It is imperative that the child be placed in a protected environment immediately; on occasion, this may require hospital admission.

This case emphasizes the need for EPs to at least consider sexual abuse in the pediatric patient with a genitourinary or rectal complaint.

Methadone Overdose: Intentional or Not

A 19-year-old woman presented to the ED via emergency medical services (EMS) unresponsive with shallow respirations. She had been found in her home by her grandmother. The paramedics brought the patient’s prescription medications to the ED, which included methadone, morphine, and naproxen. Reportedly, these medications had been prescribed by the patient’s family practitioner for chronic neck pain.

The patient was given intravenous naloxone (Narcan) and rapidly returned to her usual baseline. Her vital signs were normal and the physical examination was unremarkable. She told the EP that she had mistakenly taken the wrong dose of methadone, and vehemently denied any suicidal ideations or past attempts; she did not want to be admitted to the hospital. After several hours of observation, the patient remained in stable condition and without complaint. She was discharged home in the company of her grandmother, with instructions to continue her methadone, morphine, and naproxen, but to pay special attention to the dosage and frequency of use for each drug.

Four days later, the patient was found dead at home by her grandmother; the death was attributed to an overdose of methadone. The EP and hospital were sued by the plaintiff because of the discharge instructions to continue the same medication which had resulted in her first ED visit. The family practitioner was also sued for prescribing these medications to a patient with a history of drug abuse. At trial, it came to light that the patient had also probably ingested some illegally obtained hydrocodone/acetaminophen tablets (Vicodin). A defense verdict was returned.

Discussion

Deaths due to methadone overdose are becoming an increasing problem in the United States. In 2009 alone, more than 4 million prescriptions for methadone were written for pain patients.¹ To place this figure in perspective, between 1997 and 2007 the number of grams of methadone prescribed in the United States increased more than 1,200%.² According to US Centers for Disease Control and Prevention data from 2009, although methadone comprises approximately 2% of all analgesic prescription medications, it has been linked to more than 30% of overdose-related deaths due to prescription analgesics.¹

Two factors contribute to this problem. Since methadone is so inexpensive, many states and insurance companies list it as the preferred opioid medication on their formularies. In addition, there is also the increased emphasis on physicians to adequately control pain. This helps explain, in part, for the dramatic increase in its use.

The second factor involves the toxicokinetics of methadone. This drug has a long and often unpredictable half-life, which can lead to toxic levels resulting in respiratory depression and death.¹ Thus, methadone should only be prescribed by physicians well versed in its pharmacotherapy. Combined with the fact that there is very limited evidence supporting the use of methadone to treat acute or chronic pain unrelated to cancer, most experts agree there are better and safer alternatives.

This patient was treated appropriately in the ED regarding her resuscitation and observation. The real problem lies with the two narcotic medications she was prescribed for chronic pain. The combination of methadone and morphine in an otherwise healthy young woman probably should have raised a red flag. A conversation with the prescribing physician might have been helpful and resulted in a decrease in the dosage of one or both medications. Abrupt discontinuation, however, would not have been appropriate, since this would have resulted in opiate withdrawal and the associated effects of attending nausea, vomiting, diarrhea, diaphoresis, and abdominal cramping.

This patient was not a missed opportunity for psychiatric intervention and prevention of a suicide as there was no evidence she was ever depressed or suicidal. Rather, this was the case of a drug abuser accidently overdosing from multiple prescribed narcotic medications. It is going to take a multipronged effort to reverse this trend, including improved physician education regarding narcotic prescribing, additional resources to treat narcotic addiction, and improved identification of those at risk.

Missed Child Abuse

A 7-year-old girl was brought to the ED by her mother for discomfort with urination. The patient was otherwise healthy, up-to-date on all of her immunizations, and without any other complaints. Her vital signs were normal, and the physical examination was unremarkable. Although the chart did not reflect that a genitourinary examination was performed, the emergency physician (EP) stated that he had performed one.

A urinalysis was obtained, which was consistent with a bacterial infection. The patient was diagnosed with a urinary tract infection (UTI), prescribed an antibiotic, and discharged home with appropriate instructions.

Approximately 11 months later, it was discovered that the patient and her older sister were victims of sexual abuse by their 17-year-old stepbrother. Apparently, the abuse had started several months prior to the patient’s ED visit. The mother sued the EP and hospital for failure to recognize the signs and symptoms of sexual abuse. The plaintiff argued the child and mother should have been questioned about the possibility of sexual abuse, and that a more detailed physical examination would have shown evidence of abuse. The defense argued that the child’s presentation did not suggest sexual abuse; a defense verdict was returned.

Discussion

There are no reliable estimates of the incidence of pediatric sexual abuse in the United States. According to the most recent US Department of Health and Human Services Child Maltreatment Report, approximately 62,936 cases of child sexual abuse were reported in the United States in 2012, representing 9.3% of the total number of reported maltreatment cases that year.¹ A meta-analysis of 22 US-based studies using national, local, and regional sampling found a much higher rate. This data suggest that 30% to 40% of girls and 13% of boys experienced sexual abuse during childhood.²

For EPs, sexually abused pediatric patients usually present in one of two ways: they are presented by a caregiver based on a suspicion or a disclosure of sexual abuse; or, in the more difficult presentation, they are brought in for evaluation of symptoms related to the genitourinary system or rectum. Such symptoms include vaginal discharge or anal or vaginal bleeding, and the presence of a sexually transmitted infection or UTI. While UTI is frequently listed as a potential sign of sexual abuse in children, there are no good data to demonstrate its frequency. Compounding this problem is that approximately 3% of girls and 1% of boys in the general population are diagnosed with a UTI prior to the onset of puberty.³ Interestingly, though most texts and articles discussing pediatric sexual abuse usually include UTI as a potential sign of abuse, reviews of UTIs in pediatric patients seldom include a discussion of sexual abuse as a potential etiology.

Emergency physicians must therefore maintain a high index of suspicion when evaluating a pediatric patient with a genitourinary or rectal complaint. If the child is old enough to give a history, the caregiver(s) should be asked to leave the room and the patient questioned directly about improper touching, physical activity, etc. The genital and perianal areas should be visually inspected. In general, a speculum examination is not necessary unless vaginal penetration is suspected or the patient is an older adolescent. The majority of pediatric patients can simply be examined in the supine, frog-leg position.

Physical signs of penetration include the presence of concavities (hymen notches), especially at the 6 o’clock position. In addition, irregularities in the hymen contour may be associated with prior injury. More obvious signs of sexual abuse include the presence of warts (condyloma acuminata or lata), vesicles, ulcers, bruising, or vaginal discharge.⁴ It is important to remember that the absence of physical findings does not exclude sexual abuse.

Laboratory testing of suspected victims of sexual abuse should include cultures of the vagina and rectum for gonorrhea and chlamydia, and throat cultures for gonorrhea.⁴ Additional testing should be based on the history and physical examination.

When an EP suspects child abuse, he or she must contact child protective services and/or law enforcement agencies, as required by law. It is imperative that the child be placed in a protected environment immediately; on occasion, this may require hospital admission.

This case emphasizes the need for EPs to at least consider sexual abuse in the pediatric patient with a genitourinary or rectal complaint.

Methadone Overdose: Intentional or Not

A 19-year-old woman presented to the ED via emergency medical services (EMS) unresponsive with shallow respirations. She had been found in her home by her grandmother. The paramedics brought the patient’s prescription medications to the ED, which included methadone, morphine, and naproxen. Reportedly, these medications had been prescribed by the patient’s family practitioner for chronic neck pain.

The patient was given intravenous naloxone (Narcan) and rapidly returned to her usual baseline. Her vital signs were normal and the physical examination was unremarkable. She told the EP that she had mistakenly taken the wrong dose of methadone, and vehemently denied any suicidal ideations or past attempts; she did not want to be admitted to the hospital. After several hours of observation, the patient remained in stable condition and without complaint. She was discharged home in the company of her grandmother, with instructions to continue her methadone, morphine, and naproxen, but to pay special attention to the dosage and frequency of use for each drug.

Four days later, the patient was found dead at home by her grandmother; the death was attributed to an overdose of methadone. The EP and hospital were sued by the plaintiff because of the discharge instructions to continue the same medication which had resulted in her first ED visit. The family practitioner was also sued for prescribing these medications to a patient with a history of drug abuse. At trial, it came to light that the patient had also probably ingested some illegally obtained hydrocodone/acetaminophen tablets (Vicodin). A defense verdict was returned.

Discussion

Deaths due to methadone overdose are becoming an increasing problem in the United States. In 2009 alone, more than 4 million prescriptions for methadone were written for pain patients.¹ To place this figure in perspective, between 1997 and 2007 the number of grams of methadone prescribed in the United States increased more than 1,200%.² According to US Centers for Disease Control and Prevention data from 2009, although methadone comprises approximately 2% of all analgesic prescription medications, it has been linked to more than 30% of overdose-related deaths due to prescription analgesics.¹

Two factors contribute to this problem. Since methadone is so inexpensive, many states and insurance companies list it as the preferred opioid medication on their formularies. In addition, there is also the increased emphasis on physicians to adequately control pain. This helps explain, in part, for the dramatic increase in its use.

The second factor involves the toxicokinetics of methadone. This drug has a long and often unpredictable half-life, which can lead to toxic levels resulting in respiratory depression and death.¹ Thus, methadone should only be prescribed by physicians well versed in its pharmacotherapy. Combined with the fact that there is very limited evidence supporting the use of methadone to treat acute or chronic pain unrelated to cancer, most experts agree there are better and safer alternatives.

This patient was treated appropriately in the ED regarding her resuscitation and observation. The real problem lies with the two narcotic medications she was prescribed for chronic pain. The combination of methadone and morphine in an otherwise healthy young woman probably should have raised a red flag. A conversation with the prescribing physician might have been helpful and resulted in a decrease in the dosage of one or both medications. Abrupt discontinuation, however, would not have been appropriate, since this would have resulted in opiate withdrawal and the associated effects of attending nausea, vomiting, diarrhea, diaphoresis, and abdominal cramping.

This patient was not a missed opportunity for psychiatric intervention and prevention of a suicide as there was no evidence she was ever depressed or suicidal. Rather, this was the case of a drug abuser accidently overdosing from multiple prescribed narcotic medications. It is going to take a multipronged effort to reverse this trend, including improved physician education regarding narcotic prescribing, additional resources to treat narcotic addiction, and improved identification of those at risk.

Missed Child Abuse

A 7-year-old girl was brought to the ED by her mother for discomfort with urination. The patient was otherwise healthy, up-to-date on all of her immunizations, and without any other complaints. Her vital signs were normal, and the physical examination was unremarkable. Although the chart did not reflect that a genitourinary examination was performed, the emergency physician (EP) stated that he had performed one.

A urinalysis was obtained, which was consistent with a bacterial infection. The patient was diagnosed with a urinary tract infection (UTI), prescribed an antibiotic, and discharged home with appropriate instructions.

Approximately 11 months later, it was discovered that the patient and her older sister were victims of sexual abuse by their 17-year-old stepbrother. Apparently, the abuse had started several months prior to the patient’s ED visit. The mother sued the EP and hospital for failure to recognize the signs and symptoms of sexual abuse. The plaintiff argued the child and mother should have been questioned about the possibility of sexual abuse, and that a more detailed physical examination would have shown evidence of abuse. The defense argued that the child’s presentation did not suggest sexual abuse; a defense verdict was returned.

Discussion

There are no reliable estimates of the incidence of pediatric sexual abuse in the United States. According to the most recent US Department of Health and Human Services Child Maltreatment Report, approximately 62,936 cases of child sexual abuse were reported in the United States in 2012, representing 9.3% of the total number of reported maltreatment cases that year.¹ A meta-analysis of 22 US-based studies using national, local, and regional sampling found a much higher rate. This data suggest that 30% to 40% of girls and 13% of boys experienced sexual abuse during childhood.²

For EPs, sexually abused pediatric patients usually present in one of two ways: they are presented by a caregiver based on a suspicion or a disclosure of sexual abuse; or, in the more difficult presentation, they are brought in for evaluation of symptoms related to the genitourinary system or rectum. Such symptoms include vaginal discharge or anal or vaginal bleeding, and the presence of a sexually transmitted infection or UTI. While UTI is frequently listed as a potential sign of sexual abuse in children, there are no good data to demonstrate its frequency. Compounding this problem is that approximately 3% of girls and 1% of boys in the general population are diagnosed with a UTI prior to the onset of puberty.³ Interestingly, though most texts and articles discussing pediatric sexual abuse usually include UTI as a potential sign of abuse, reviews of UTIs in pediatric patients seldom include a discussion of sexual abuse as a potential etiology.

Emergency physicians must therefore maintain a high index of suspicion when evaluating a pediatric patient with a genitourinary or rectal complaint. If the child is old enough to give a history, the caregiver(s) should be asked to leave the room and the patient questioned directly about improper touching, physical activity, etc. The genital and perianal areas should be visually inspected. In general, a speculum examination is not necessary unless vaginal penetration is suspected or the patient is an older adolescent. The majority of pediatric patients can simply be examined in the supine, frog-leg position.

Physical signs of penetration include the presence of concavities (hymen notches), especially at the 6 o’clock position. In addition, irregularities in the hymen contour may be associated with prior injury. More obvious signs of sexual abuse include the presence of warts (condyloma acuminata or lata), vesicles, ulcers, bruising, or vaginal discharge.⁴ It is important to remember that the absence of physical findings does not exclude sexual abuse.

Laboratory testing of suspected victims of sexual abuse should include cultures of the vagina and rectum for gonorrhea and chlamydia, and throat cultures for gonorrhea.⁴ Additional testing should be based on the history and physical examination.

When an EP suspects child abuse, he or she must contact child protective services and/or law enforcement agencies, as required by law. It is imperative that the child be placed in a protected environment immediately; on occasion, this may require hospital admission.

This case emphasizes the need for EPs to at least consider sexual abuse in the pediatric patient with a genitourinary or rectal complaint.

Methadone Overdose: Intentional or Not

A 19-year-old woman presented to the ED via emergency medical services (EMS) unresponsive with shallow respirations. She had been found in her home by her grandmother. The paramedics brought the patient’s prescription medications to the ED, which included methadone, morphine, and naproxen. Reportedly, these medications had been prescribed by the patient’s family practitioner for chronic neck pain.

The patient was given intravenous naloxone (Narcan) and rapidly returned to her usual baseline. Her vital signs were normal and the physical examination was unremarkable. She told the EP that she had mistakenly taken the wrong dose of methadone, and vehemently denied any suicidal ideations or past attempts; she did not want to be admitted to the hospital. After several hours of observation, the patient remained in stable condition and without complaint. She was discharged home in the company of her grandmother, with instructions to continue her methadone, morphine, and naproxen, but to pay special attention to the dosage and frequency of use for each drug.

Four days later, the patient was found dead at home by her grandmother; the death was attributed to an overdose of methadone. The EP and hospital were sued by the plaintiff because of the discharge instructions to continue the same medication which had resulted in her first ED visit. The family practitioner was also sued for prescribing these medications to a patient with a history of drug abuse. At trial, it came to light that the patient had also probably ingested some illegally obtained hydrocodone/acetaminophen tablets (Vicodin). A defense verdict was returned.

Discussion

Deaths due to methadone overdose are becoming an increasing problem in the United States. In 2009 alone, more than 4 million prescriptions for methadone were written for pain patients.¹ To place this figure in perspective, between 1997 and 2007 the number of grams of methadone prescribed in the United States increased more than 1,200%.² According to US Centers for Disease Control and Prevention data from 2009, although methadone comprises approximately 2% of all analgesic prescription medications, it has been linked to more than 30% of overdose-related deaths due to prescription analgesics.¹

Two factors contribute to this problem. Since methadone is so inexpensive, many states and insurance companies list it as the preferred opioid medication on their formularies. In addition, there is also the increased emphasis on physicians to adequately control pain. This helps explain, in part, for the dramatic increase in its use.

The second factor involves the toxicokinetics of methadone. This drug has a long and often unpredictable half-life, which can lead to toxic levels resulting in respiratory depression and death.¹ Thus, methadone should only be prescribed by physicians well versed in its pharmacotherapy. Combined with the fact that there is very limited evidence supporting the use of methadone to treat acute or chronic pain unrelated to cancer, most experts agree there are better and safer alternatives.

This patient was treated appropriately in the ED regarding her resuscitation and observation. The real problem lies with the two narcotic medications she was prescribed for chronic pain. The combination of methadone and morphine in an otherwise healthy young woman probably should have raised a red flag. A conversation with the prescribing physician might have been helpful and resulted in a decrease in the dosage of one or both medications. Abrupt discontinuation, however, would not have been appropriate, since this would have resulted in opiate withdrawal and the associated effects of attending nausea, vomiting, diarrhea, diaphoresis, and abdominal cramping.

This patient was not a missed opportunity for psychiatric intervention and prevention of a suicide as there was no evidence she was ever depressed or suicidal. Rather, this was the case of a drug abuser accidently overdosing from multiple prescribed narcotic medications. It is going to take a multipronged effort to reverse this trend, including improved physician education regarding narcotic prescribing, additional resources to treat narcotic addiction, and improved identification of those at risk.