Mr. R, 38, had worked as a physician assistant in the emergency department (ED)of a small hospital in the Midwest for nine years. He often recognized many of the patientsin the waiting room —“repeat customers” he termed them.
Mrs. K was one of them. A divorced mother of four rambunctious boys ranging from 11 to 17 years old, she was frequently at the ED with one son or another after a sports injury, a fall from a tree, or a bout of strep throat or flu.
This time the patient was her youngest son, Johnny. “He’s had a fever for the last day or two, and his head hurts,” Mrs. K told Mr. R. Johnny said his headache had begun the previous day and pointed to “spots” on his wrists and lower arms.
Mr. R examined the mild rash consisting of small, flat, pink, nonpruritic maculae. The boy’s temperature was 101.8°F. No other symptoms were reported or apparent. Mr. R diagnosed infection with a nonspecific virus, which, he said, would probably resolve in a day or so.
“Give Johnny acetaminophen for the headache and fever,” he counseled. “Make sure he drinks plenty of fluids and rests, and he should be fine. If he doesn’t feel better in a couple of days, take him to the pediatric division.”
A few days later, Mr. R got a call from a pediatric clerk. “Mrs. K was here with her son. She said you sent her. The boy didn’t look great. He had a rash on his arms and legs, a fever, and body aches.”
By the time Johnny saw the pediatrician, it was clear that something was very wrong. The petechiae on his arms had spread to his palms, legs, and the soles of his feet. His joints hurt, and the fever had not abated. Suspecting Rocky Mountain spotted fever (RMSF), the attending pediatrician admitted him and began a course of doxycycline. But the disease was so advanced that the antibiotic was of little use.
Johnny developed gangrene in both legs and in four fingers on one hand and one on the other. Both limbs and all five digits had to be amputated, leading to painful skin grafts. Johnny also lost his hearing, most of his ability to communicate, and considerable muscle control.
His distraught mother quit her job to become his full-time caregiver. A friend then suggested she contact an attorney to see whether the hospital could be sued for malpractice by not treating Johnny promptly.
In researching the case, the attorney learned RMSF can be difficult to diagnose, especially if neither the patient nor the clinician notices a tick bite. He also learned that the timely administration of a tetracycline can prevent the disease from taking a catastrophic turn. The lawyer decided to take the case and filed a lawsuit against the hospital and Mr. R.
Johnny’s condition left Mr. R wracked with guilt. He spent many a sleepless night reviewing the initial exam, wondering why he hadn’t suspected RMSF, and obsessing about what the outcome might have been had he prescribed doxycycline.
Discovery, deposition, and pretrial motions dragged on for almost a decade before the case finally went to trial. Johnny sat in his wheelchair at the plaintiffs’ table as his lawyer described the energetic, athletic boy the young man had once been.
Now, the lawyer declared, his client had brain damage and was deaf, a multiple amputee, and unable to do anything for himself. The fault clearly rested with the PA who couldn’t diagnose the disease and with the hospital that employed him.
The plaintiffs’ first witness was an infectious disease expert who explained that RMSF is a rickettsial illness. Symptoms include a petechial rash, malaise, fever, headache, muscle aches, and sometimes GI distress.
The most serious of all tick-borne diseases, RMSF can be treated fairly easily and successfully with a tetracycline antibiotic, such as doxycycline. But treatment must start immediately. Any delay can lessen the patient’s chance at recovery.
“It’s highly likely that if Johnny had been treated when his symptoms first appeared, he would not have experienced the serious long-term complications that he has been suffering,” the expert asserted.
Under cross-examination, the expert acknowledged that RMSF is rare, with fewer than 1,200 cases reported each year, and difficult for even experienced clinicians to diagnose.
“Many of the symptoms are common and indicative of other diseases,” he explained. “Generally there are three key factors for suspecting this disease: fever, rash, and tick bite. Serologic assays will confirm a diagnosis, but treatment often needs to begin before the test results come back.”
The next witness was Mrs. K, whose heartrending description of Johnny’s daily life had most of the jury in tears.
The defense attorney had only one question: “Did you or Johnny know that he had been bitten by a tick, and if so, did you mention this to Mr. R?”
“No,” she conceded. “We didn’t know he’d been bitten.”
The trial continued for five grueling weeks. In his closing arguments, the plaintiffs’ attorney charged that had Johnny been properly treated, he would be a normal young man, perhaps graduating from college or getting married soon.
The defense attorney emphasized the rarity of the disease and the vagueness of its symptoms. Besides, he argued, since Johnny’s tick bite was not apparent and neither he nor his mother mentioned it, there was little reason to suspect RMSF.
But the jury disagreed. It awarded Johnny $9 million, including more than $5 million for pain and suffering.
Jurors are only human and are often moved by tragic stories. Having Johnny in the courtroom so that they saw his condition daily probably was instrumental in returning such a large verdict. However, the state where this case took place has a cap of $250,000 on damages for pain and suffering. Johnny will probably receive less than $4 million of the award.
Experts agree that RMSF is difficult to diagnose and treatment should not be delayed for lab results. Absent an obvious tick bite, here are facts from the CDC worth remembering:
• More than 90% of patients are infected between April and September;
• Two of three patients are younger than 15;
• More than half of RMSF infections are reported from Southeastern states;
• People with frequent exposure to dogs or who live in grassy areas may be at increased risk of tick bites and infection.
If you suspect RMSF, start a course of antibiotics immediately; don’t wait for lab confirmation of your diagnosis.