The plaintiff took her two-month old son to the emergency department because he was not eating or sleeping. In triage, the infant's breathing was noted to be shallow and rapid; his color was pale; fontenelles were sunken; the abdomen noted as tense; bowel sounds were decreased, and the child was described as lethargic. The physician's note indicated that the baby had "trouble breathing" and was "glassy-eyed". After four hours without intervention or treatment, the infant went into respiratory arrest. CPR was initiated, but the child was intubated into the esophagus. He was pronounced dead after prolonged resuscitation efforts. The death certificate listed septicemia, dehydration, and enterocolitis as the cause of death. The defense denied that the infant was critically ill upon presentation, deteriorated rapidly, and could not have been saved with quicker intervention. According to published accounts, a confidential settlement was reached prior to trial.

Commentary: Children less than six months old need extensive evaluation and observation when presenting to the emergency department for vomiting, dehydration, fever or change in mental/behavior status. These complaints should immediately increase your index of suspicion and prompt immediate evaluation of the infant. As emergency physicians, we are responsible for the patient as soon as they enter the emergency department, and it is incumbent on us to ensure that potentially sick patients are identified as soon as possible.

Children typically are resilient and have some reserve, but when they begin to crash, it can occur quickly and is often irreversible. Laboratory evaluation, intravenous fluids and rapid empiric antibiotics are excellent modalities in the work- up of any child less than six months of age who presents with dehydration, fever, or change in mental/behavioral status. A high index of suspicion and an aggressive and timely evaluation and treatment, while not quaranteed, would certainly have been appropriate, more defensible and may have well resulted in a successful outcome.


The plaintiff, age fourteen, was diagnosed with bacterial meningitis shortly after she was born and sustained permanent hearing loss. The plaintiff also suffered with hydrocephalus from birth. Shunts were placed to drain fluid. The plaintiff had had multiple shunts during her fourteen years. In May 2000, she presented to the local emergency room with complaints of headaches, sleeping a lot, difficulty walking and not eating. She had missed several days of school. The defendant emergency room physician suspected hydrocephalus and ordered a CT scan of the brain. The radiologist reported orally and in writing to the defendant that the ventricles were much larger than the comparative scan taken in January of that year. The defendant discharged the plaintiff with a diagnosis of sinus cephaliga and hydrocephalus. The plaintiff suffered a herniation of the brain before a new shunt could be placed and she became a quadriplegic. The plaintiff claimed that the defendant should have admitted her to the hospital or contacted a neurosurgeon for consultation and replacement of the shunt. According to Ohio Trial Reporter, a $3.5 million settlement was reached.

Commentary: The presentation of shunt malfunction is often subtle and requires an ED physician to have a low threshold for consultation of a neurosurgeon. Symptoms include headache, nausea, vomiting, personality changes, increased head circumference in infants with non-fused cranial bones and classically sun downing of the eyes. Key for discovering malfunction of the shunt is a current CT compared to previous scans. The findings of increased hydrocephalus are highly suggestive of the diagnosis. If in doubt, the patient should be admitted, transferred or consult a neurosurgeon for evaluation.