Commentary

Rory has been shaken by his father and sustained a subdural haematoma amongst other intracranial damage. This is perhaps the last thing to come out of the history as the mother is not aware of this, the child too young to speak, and health services focused on dealing with other possibilities. There are clues throughout – the ‘ringworm’ is bite marks, there is a fractured clavicle on the chest radiograph and the child has a CNS disorder without real signs of infection.

The case is hard to manage, and important alternate diagnoses need considering – especially encephalitis and meningitis which need early antibiotic treatment. Whatever choice is made, the child will still fit. The outcome is better if this happens in hospital. Good choices are needed as the case progresses – the wrong ones lead to fatalities.

This case requires players to recognize the severity of the situation and act proportionately – timely referral, recognition of increasing intracranial pressure, and keeping control of the situation. One of the temptations in medicine is to opt for observing when something needs doing. This case explores what happens when that something is not done.

Decision step 1:       Triage, Teamwork, Skill, Playing the odds

Infants are hard to assess. They rarely have specific symptoms or signs. Parents are often good at identifying when there is something wrong, but not able to work out what it is. One of the key tasks for a doctor assessing an infant is to identify how sick the child is. Here subtle clues abound – unsettled feeding, irritability and an altered cry. He is a little tachycardic and pale, suggesting a systemic problem.

Such a child, even without a diagnosis, needs to be assessed by someone who knows children well – a paediatrician – and fairly rapidly.

Knowing what the cause at this stage is not important. The runny nose might suggest a viral infection, which are of course very common in children. The marks – there is a café-au-lait mark in the axilla and a blue spot at the top of the natal cleft – are longstanding and no cause for alarm. The circular marks are bite marks. These would be obvious to anyone who has seen bite marks, but not to those less experienced. Ringworm (fungal skin infection) is also common, but does not appear suddenly.

The errors that are possible here revolve around not appreciating how ill the child is, that you (the player) will not be able to solve the case alone, and in avoiding going along with the implied wishes of the mother.

Patients typically want to believe the best for themselves, and doctors tend to collude with this. It is not pleasant telling a patient about their serious condition, and we tend to avoid this if possible. Hence mild or self limiting diagnoses are favoured. The same applies with parents and children. Here, although there are suggestions the baby may be seriously ill, they may also have a self limiting viral problem or mild infection. So doctors will typically select these over (for instance) meningitis or non-accidental injury.

It is quite natural for healthcare professionals to enjoy thanks from their patients. Thanks is usually offered when the patient gets what they hoped for. In this case the doctor gets thanked when that which the mother expected, but this is not necessarily the right decision for the patient.

Decision step 2: Skill, Knowledge, bravado/timidity, playing the odds

In this step, no matter what previous decisions have been made in the case, the  same options are possible following the resolution of the seizure. The team that have helped control the seizure leave. Typically professionals are pleased when they do what they set out to do. In this case it is simply controlling a seizure, which is very different from identifying and managing the cause of the seizure.

At this stage in any case, there is often a flood of information. Here we learn some more of the history, a chest radiograph is presented and the player can review the skin markings and some blood tests. One of the challenges at this stage is working out what in the information presented is relevant.

There are three options – one overly timid, one with too much bravado, and one that treats what is treatable and finds out more information safely.

The baby has had a seizure and is now very slightly febrile. By this stage it should be obvious that there is a brain disorder. However in children, (very benign) febrile convulsions are a very common cause of seizures. Rory’s seizure may be confused with a febrile convulsion, but he is too young, really has no fever and was not right before his seizure. Although students without this knowledge might think a febrile seizure is most likely (playing the odds), this ignores the nature of the presentation. The seizure sounds unlike a febrile seizure and suggests a brain disorder. At this stage it is not completely clear what that is, and meningitis or encephalitis may be the cause. Antibiotics are needed, and CSF culture would help to establish the diagnosis, if safe to do.

Lumbar puncture is indicated for a variety of brain disorders to make a diagnosis. We like diagnoses. However it is not always safe, practical or appropriate to do a diagnostic procedure. For lumbar puncture, it is not safe include cardiorespiratory instability and possible raised intracranial pressure.

Intracranial pressure is measured with a manometer attached to a spinal needle, requiring a lumbar puncture! Therefore other clinical features and investigations need to be used to predict the high ICP. The low level of consciousness and full fontanelle suggest the ICP is high. Those exhibiting bravado would be keen to do the LP to make a diagnosis, but this would be dangerous for the child.

In the real world, a CT scan is often used to assess ICP, but it is not suitable to exclude raised ICP alone.

In this situation, a lumbar puncture is clearly dangerous, and observing the child inadequate to manage the intracranial pathology.

One clear priority in all cases is to look for and treat conditions that are treatable. Many conditions have no specific treatment – supportive measures are all that can be offered. Infectious, surgical and inflammatory conditions do need specific treatment, and if they cannot be excluded, treatment should be started.

At this stage in the case, it is possible that an intracranial bleed, hydrocephalus a mass or CNS infection may be the cause of the baby’s abnormal conscious level and seizure. The mass/blood causes can be excluded with a CT scan and CNS infection should treated in the absence of a positive culture and before the LP because of the severity of the child’s condition. 

Decision Step 3: Triage, System, Knowledge, Skill

In this last step the child is now moderately stable, but depending on the care to this stage, deteriorating. There are still two problems: the diagnosis is perhaps still not clear. The father is attempting to remove the child.

If the player loses control of the case, the child will die at home. This will occur in steps that have take the player away from the child – observing, allowing home. The child may also end up ventilated – this following the lumbar puncture. There are distractions in the case, and this is typical for a normal paediatric service. It could be described as a system problem, although a system should be designed to accommodate multiple simultaneous problems. How could this happen?

The diagnosis could be clear from the CT scan which shows multiple ages subdural haemorrhage. This is diagnostic of child abuse unless a medical cause (eg clotting problem) is not identified. Players may not be skilled in reading CT scans to this level. If not, the skeletal survey and ophthalmology review are very useful. The skeletal survey however requires extensive manipulation in radiology, not the sort of thing that a sick baby would safely tolerate. It also talks about past trauma to the body, rather than injury to the brain. The retinal examination has the substantial advantage of focusing on the abnormal organ (brain/head) and being possible in an ITU/HDU environment, making it useful in the context of an unwell child.

I hope you have found this difficult and challenging case worthwhile for paediatrics and medical error learning.