This case involved alleged negligent failures on the part of the defendant pediatricians to properly assess and treat a sports related ankle injury in a nine-year-old boy who, in rapid order, went on to develop a systemic inflammatory response due to presumed sepsis which rapidly lead to a coagulopathy and purpura fulminans resulting in compartment syndrome to the involved leg and then gangrene to all of the boy’s extremities necessitating life saving amputations of the boy’s legs and hands.
The patient was seen by our pediatrician late in the afternoon on a Friday as an acute visit for a sports-related injury to the ankle which had occurred the day before. A review of systems with the boy and his parents reported no other acute complaints. The child had no other significant health issues by history. Accordingly, the Doctor’s physical examination was localized to the boy’s right ankle and no vital signs were taken. The boy’s ankle was edematous and ecchymotic and was tender. There were no apparent cuts, scrapes or abrasions to the ankle and range of motion of the ankle was fully intact upon exam. An x-ray was secured to rule out fracture which was interpreted by a radiologist as being negative and without evidence of soft tissue damage. The parents were instructed to have their son rest and elevate the leg and to apply ice and administer ibuprofen to reduce the swelling. The parents were told to call if their son developed new symptoms or if they had any concerns. By all accounts, but for the pain in his ankle, there were no changes in the boy’s condition the remainder of Friday and he slept through the night.
Late Saturday morning, the boy awoke feeling ill with a temperature and occasional diarrhea. The mother telephoned the pediatric practice around 1:30 pm and reported her son’s ankle injury and visit to the doctor the day before with a negative x-ray and that her son was complaining that the pain was moving up the leg and that he had the new onset of fever ranging between 101 and 104 along with a couple episodes of diarrhea. Communication with the mother and on-call defendant pediatrician were through a medical assistant. The doctor attributed the increase in leg pain to the report that the boy had been ambulating somewhat and the fever and diarrhea were thought to represent an unrelated viral gastroenteritis. Based upon the telephone exchange of information, the Doctor did not believe that a visit was warranted. Instructions to reinforce that the boy stay off of his leg along with diet and fluid directions to address the fever and diarrhea complaints were issued. By the account of the parents, the appearance of their son’s ankle did not change throughout the remainder of Saturday.
At around 2:00 am on Sunday morning, the boy awoke with an episode of vomiting. He had panting respirations and was observed by the mother to be flushed with blue lips (cyanotic). The boy was taken immediately by the mother to the emergency department. En route to the hospital, the boy became increasingly short of breath and upon his arrival at the hospital he was found to be in extremis with suspected septic or toxic shock. All blood cultures were negative for growth. Antibiotics, oxygen and fluid therapy were administered in the ED and he was promptly transferred to a tertiary PICU facility where he rapidly developed DIC and purpura fulminans which led to the required limb amputations. A year following his amputations, testing revealed the presence a heterozygous Factor V Leiden genetic blood clotting functioning abnormality. The Leiden mutation causes resistance to the activation of antithrombin protein C which is essential to the blood’s normal clotting cascade balance which normal blood Factor V is designed to initiate. Thus, people with the Factor V Leiden mutation are predisposed to developing thrombosis and thrombemboli.
During the ten day trial, the defense emphasized the extreme rarity of this event and that even today, no one knows definitively what happened to this boy. Despite negative cultures, the experts assumed that there must have been a bacterial infection involved here that acted in concert with the inflammation associated with the ankle trauma and the later discovered Factor V Leiden blood clotting anomaly to create the perfect storm in this child. The defense presented exceptionally distinguished experts in the fields of general pediatrics, pediatric hematology, pediatric infectious disease and pediatric critical care from Georgetown, Harvard and Johns Hopkins.
Economic damages in the case were black-boarded in excess of $15 million dollars. The ten day twelve member jury trial resulted in a unanimous verdict for our pediatrician clients. The case was defended by Margolis Edelstein partner, Michael M. Badowski.