This case is absolutely heartbreaking. I'm bilingual (medical school in Mexico, residency in the US) and there have been a few occasions that I have relied on interpreters to ensure that Spanish speaking patients are clear on diagnosis, treatment plan, return instructions. Cultural factors that are not present in English speaking culture can also play an important role.
There seems to have been so much bias in this patient's care-minimizing mother's concerns, ignoring red flags, dismissing a major diagnosis. Racial, cultural and gender bias can affect patient care to such a degree, and no progress is being made to improve it. in fact, seems to be going backward.
I'm hoping this case serves as a reminder to everyone that these concerns and biases actually do affect patient care, can result in harm to innocent children, and will get you sued if you're flippant about them.
Wow- you have a tremendous advantage. One issue that I have- if I’m speaking with someone who speaks English- I can watch the person’s eyes while speaking to them and adjust in real time. A lot of the time Spanish speaking patients won’t request an interpreter- I’ve noticed. But almost every time I have INSISTED on having one present it’s been helpful. Sometimes the patient speaks enough English to live day to day. Most of the conversation may occur in English with patient looking to the interpreter for assistance when trying to describe a symptom or when I’m talking about diagnosis/ treatment.
I had one patient where daughter was not telling the patient what I was as actually saying (I understand a lot). When I offered an interpreter THAT time the daughter accused me of being a racist who thinks all Latino people can’t speak English (patient could not). Then she fired me. I was stunned because I’m passive - I don’t tend to arouse peoples’ wrath. My feelings were hurt and I have since tried to be extra extra undeniably tactful
Absolutely, understanding the cultural issues and barriers to communication are essential to proper communication. (yes, I was lucky, although I struggled in residency against the bias for being an FMG (I'm a US born, blond haired white woman LOL)
Using family members (especially the patient's child) is fraught. particularly in Latinx cultures the expected deference and expectation of privacy can really impede getting the whole picture. Good luck to you!
This is awful. The ophthalmologist defense is shameless. The difference between total blindness, loosing one vs two eyes, vs seeing shapes and colors are all very different outcomes. They absolutely dismissed this parent and child. A kid falling so much should have been taken more seriously, if not retinoblastoma, there are other CNS abnormalities and tumors to consider.
The fact the pediatrician kept billing for some eye procedure is absurd, he didn't do anything useful and is just as guilty as the ophthalmologist. He only checked a white reflex after the diagnosis, ridiculous.
This was hard to read... I think you should have included the option of "were both equally to blame" in the poll. The pediatrician was so very arrogant/dismissive, cutting corners and the ophtalmologist just shockingly incompetent. This poor child.
Dr K is definitely at fault as a cycloplegic dilated exam is mandatory for a diagnosis of esotropia anyhow. A pediatric ophthalmologist's office should also have an orthoptist (who should have also checked the light reflex prior to dilation). The mother's complaints or lack of complaints have nothing to do with it. A child with crossed eyes needs a dilated exam. We have papooses and restraints for older children for a reason -- we have to look in their eyes!
As a retinal ophthalmologist this is heartbreaking. There is no mention of what therapy occurred after the diagnosis. However, if the left eye was diagnosed earlier, treatment may have been able to save the eye with at least hand motions or even finger counting vision. The difference between this limited amount of vision and enucleation with bilateral NLP ( no light perception) vision is huge in a developing child.I am assuming this was not a trilateral case with pineal gland involvement, but the risk of death is a real issue in these cases as well. I recognize Google Translate wasn’t as useful in 2015, but I find it very useful now when there is a language barrier with the patient.
Wow, this case is right up your alley! Yeah, they didn't mention what the downstream treatments were but the follow-up was at an Ivy League department so I'm sure they got good care once diagnosed. One challenge with ophtho cases is that the plaintiffs attorneys always say the patient was permanently blind, and its hard to know if that's just a layman's description of severely reduced vision or hand motion, etc... I hadn't heard of "trilateral" retinoblastoma, thanks for teaching me something!
Yes. There’s a big difference between legally blind, which is vision of 20/200 in the better eye or even 20/20 with tunnel vision, compared to finger counting, hand motions, light perception, and no light perception. A 20/200 blind person is much better off than a no light perception person. However both are “blind”
A sobering reminder that making sure patients are heard (by actually listening to them...) is an essential part of good medical care. I am peds EM. Parents often bring cell phone photos of things they're worried about regarding their children (eg their poop, a rash, a weird sound/movement) and while it takes a bit longer, I consider it 100% worthwhile to look at this additional data. I have actually diagnosed a child with a life threatening condition based on this extra intel, it was missed by several prior physicians because no one bothered to either look or ask for photos. Since that incident, I now proactively ask for photos/videos and I encourage all parents to document their kids conditions using their phones as well. I also proactively ask if they've Googled anything they want to discuss. Taking the time to unearth these hidden concerns reduces bouncebacks, helps patients feel heard and cared for, and every now and then can actually improve your diagnosis and management. It is possible to still be productive while including these extra steps as a routine part of your initial H&P, I promise!
That's a good point, it's easy to feel a little annoyed when people want to show us yet another picture of some blood in a toilet. I find its incredibly rare when the photo or video changes management at all, but every now and then its critical. I find the bigger benefit is that if we don't look at what they want us to see, it fractures the therapeutic connection which leads to angry family members (very emotionally distracting during a shift) and makes people much more likely to sue if anything goes wrong.
Yep, I think we can all use the reminder. I'm not sure any of us are humble all the time, we all have our moments because we're human, but its smart to reflect on these cases and try to minimize the odds they happen to us.
I admit that I don’t check it for it in the ER, but I remember the red reflex test being basic enough that I checked it on every child when I was in med school. I guess maybe it’s something that’s more rigorously checked for neonates and then less so for older babies? Regardless, the fact that the Ophtho missed the diagnosis, regardless of whether or not it would have made a treatment difference, sounds like definite malpractice. I expect that they’ll settle. Kind of surprised they haven’t yet.
Yeah me too... now one counterpoint is that most of the really inflammatory allegations (that mom repeatedly said his eye was yellow, was running into things, etc...) all come from the mom's affidavit, which was written after the fact. So maybe the defense is going to argue that it wasn't as clear cut as the plaintiff is claiming here.
This might be a trickier one to settle. I have to imagine the plaintiffs are asking for a massive settlement well beyond typical policy limits. They are likely pricing in the high likelihood of a nuclear verdict if a jury gets their hands on this and hears about a little kid rendered blind for life after mom's concerns were repeatedly brushed off.
Although the pediatrician appears to be a bit dismissive (per the post), Primary Care Providers (PCPs) simply MUST rely on the expert opinions of the experts.
The ophthalmologists first involved probably felt they were initially correct. However, when the "nervous mommy" kept cycling back with objective signs and symptoms (running into things, falling, bruises on head, etc.), vigilance would suggest (require?) more. Negligence.
The pediatrician might have saved himself (and the patient's vision) he he LISTENED to the mother, hearing her concerns, and then himself referring child to a different specialist-- all with thorough and complete documentation.
Apparently, everything "WASN'T alright." This makes BOTH providers culpable (be it to differing degrees of fault).
That's interesting, am I reading this right that the white eye was actually just because the optic disc was perfectly in view of the smartphone camera?
Yes - light reflecting off the nasal aspect of the retina. About 20 years ago, when our daughter was a toddler, we saw this on a series of digital photos (pre-smartphone). We were able to get an ophtho eval quickly, and it turned out to be benign - the combination of flash and the way she looked at the camera. As for the case you posted - social situation matters a lot.... we were able to get in quickly, but the parent and child you discussed got dismissed and delayed terribly.
There's no way this gets settled, right? I would imagine the defense knows that this case would be devastating to take in front of a jury but the family knows that too and is probably asking for an amount way beyond policy limits. But then again I guess there's no such thing as a guaranteed win when a jury can act in an unpredictable way.
I have no idea on this one... I'm not trying to sound flippant but its "just" blindness as opposed to a dead child, or a severely disabled child. Time will tell!
This case is absolutely heartbreaking. I'm bilingual (medical school in Mexico, residency in the US) and there have been a few occasions that I have relied on interpreters to ensure that Spanish speaking patients are clear on diagnosis, treatment plan, return instructions. Cultural factors that are not present in English speaking culture can also play an important role.
There seems to have been so much bias in this patient's care-minimizing mother's concerns, ignoring red flags, dismissing a major diagnosis. Racial, cultural and gender bias can affect patient care to such a degree, and no progress is being made to improve it. in fact, seems to be going backward.
I'm hoping this case serves as a reminder to everyone that these concerns and biases actually do affect patient care, can result in harm to innocent children, and will get you sued if you're flippant about them.
Wow- you have a tremendous advantage. One issue that I have- if I’m speaking with someone who speaks English- I can watch the person’s eyes while speaking to them and adjust in real time. A lot of the time Spanish speaking patients won’t request an interpreter- I’ve noticed. But almost every time I have INSISTED on having one present it’s been helpful. Sometimes the patient speaks enough English to live day to day. Most of the conversation may occur in English with patient looking to the interpreter for assistance when trying to describe a symptom or when I’m talking about diagnosis/ treatment.
I had one patient where daughter was not telling the patient what I was as actually saying (I understand a lot). When I offered an interpreter THAT time the daughter accused me of being a racist who thinks all Latino people can’t speak English (patient could not). Then she fired me. I was stunned because I’m passive - I don’t tend to arouse peoples’ wrath. My feelings were hurt and I have since tried to be extra extra undeniably tactful
Absolutely, understanding the cultural issues and barriers to communication are essential to proper communication. (yes, I was lucky, although I struggled in residency against the bias for being an FMG (I'm a US born, blond haired white woman LOL)
Using family members (especially the patient's child) is fraught. particularly in Latinx cultures the expected deference and expectation of privacy can really impede getting the whole picture. Good luck to you!
This is awful. The ophthalmologist defense is shameless. The difference between total blindness, loosing one vs two eyes, vs seeing shapes and colors are all very different outcomes. They absolutely dismissed this parent and child. A kid falling so much should have been taken more seriously, if not retinoblastoma, there are other CNS abnormalities and tumors to consider.
The fact the pediatrician kept billing for some eye procedure is absurd, he didn't do anything useful and is just as guilty as the ophthalmologist. He only checked a white reflex after the diagnosis, ridiculous.
This was hard to read... I think you should have included the option of "were both equally to blame" in the poll. The pediatrician was so very arrogant/dismissive, cutting corners and the ophtalmologist just shockingly incompetent. This poor child.
Dr K is definitely at fault as a cycloplegic dilated exam is mandatory for a diagnosis of esotropia anyhow. A pediatric ophthalmologist's office should also have an orthoptist (who should have also checked the light reflex prior to dilation). The mother's complaints or lack of complaints have nothing to do with it. A child with crossed eyes needs a dilated exam. We have papooses and restraints for older children for a reason -- we have to look in their eyes!
Shocking and sad.
How do you not check a red-reflex in a child? That may be the only thing I remember from my pediatrics rotation.
As a retinal ophthalmologist this is heartbreaking. There is no mention of what therapy occurred after the diagnosis. However, if the left eye was diagnosed earlier, treatment may have been able to save the eye with at least hand motions or even finger counting vision. The difference between this limited amount of vision and enucleation with bilateral NLP ( no light perception) vision is huge in a developing child.I am assuming this was not a trilateral case with pineal gland involvement, but the risk of death is a real issue in these cases as well. I recognize Google Translate wasn’t as useful in 2015, but I find it very useful now when there is a language barrier with the patient.
Wow, this case is right up your alley! Yeah, they didn't mention what the downstream treatments were but the follow-up was at an Ivy League department so I'm sure they got good care once diagnosed. One challenge with ophtho cases is that the plaintiffs attorneys always say the patient was permanently blind, and its hard to know if that's just a layman's description of severely reduced vision or hand motion, etc... I hadn't heard of "trilateral" retinoblastoma, thanks for teaching me something!
Yes. There’s a big difference between legally blind, which is vision of 20/200 in the better eye or even 20/20 with tunnel vision, compared to finger counting, hand motions, light perception, and no light perception. A 20/200 blind person is much better off than a no light perception person. However both are “blind”
A sobering reminder that making sure patients are heard (by actually listening to them...) is an essential part of good medical care. I am peds EM. Parents often bring cell phone photos of things they're worried about regarding their children (eg their poop, a rash, a weird sound/movement) and while it takes a bit longer, I consider it 100% worthwhile to look at this additional data. I have actually diagnosed a child with a life threatening condition based on this extra intel, it was missed by several prior physicians because no one bothered to either look or ask for photos. Since that incident, I now proactively ask for photos/videos and I encourage all parents to document their kids conditions using their phones as well. I also proactively ask if they've Googled anything they want to discuss. Taking the time to unearth these hidden concerns reduces bouncebacks, helps patients feel heard and cared for, and every now and then can actually improve your diagnosis and management. It is possible to still be productive while including these extra steps as a routine part of your initial H&P, I promise!
That's a good point, it's easy to feel a little annoyed when people want to show us yet another picture of some blood in a toilet. I find its incredibly rare when the photo or video changes management at all, but every now and then its critical. I find the bigger benefit is that if we don't look at what they want us to see, it fractures the therapeutic connection which leads to angry family members (very emotionally distracting during a shift) and makes people much more likely to sue if anything goes wrong.
Great insight in item #2. So important to approach every case with curiousity and an open mind. Humility is an underrated asset.
Yep, I think we can all use the reminder. I'm not sure any of us are humble all the time, we all have our moments because we're human, but its smart to reflect on these cases and try to minimize the odds they happen to us.
I admit that I don’t check it for it in the ER, but I remember the red reflex test being basic enough that I checked it on every child when I was in med school. I guess maybe it’s something that’s more rigorously checked for neonates and then less so for older babies? Regardless, the fact that the Ophtho missed the diagnosis, regardless of whether or not it would have made a treatment difference, sounds like definite malpractice. I expect that they’ll settle. Kind of surprised they haven’t yet.
Yeah me too... now one counterpoint is that most of the really inflammatory allegations (that mom repeatedly said his eye was yellow, was running into things, etc...) all come from the mom's affidavit, which was written after the fact. So maybe the defense is going to argue that it wasn't as clear cut as the plaintiff is claiming here.
This might be a trickier one to settle. I have to imagine the plaintiffs are asking for a massive settlement well beyond typical policy limits. They are likely pricing in the high likelihood of a nuclear verdict if a jury gets their hands on this and hears about a little kid rendered blind for life after mom's concerns were repeatedly brushed off.
Although the pediatrician appears to be a bit dismissive (per the post), Primary Care Providers (PCPs) simply MUST rely on the expert opinions of the experts.
The ophthalmologists first involved probably felt they were initially correct. However, when the "nervous mommy" kept cycling back with objective signs and symptoms (running into things, falling, bruises on head, etc.), vigilance would suggest (require?) more. Negligence.
The pediatrician might have saved himself (and the patient's vision) he he LISTENED to the mother, hearing her concerns, and then himself referring child to a different specialist-- all with thorough and complete documentation.
Apparently, everything "WASN'T alright." This makes BOTH providers culpable (be it to differing degrees of fault).
https://publications.aap.org/pediatrics/article-abstract/155/4/e2024068701/201262/Smartphone-Detected-Physiologic-Photoleukocoria
This is from Pediatrics April 2025
Digital photos can provide an early clue that further evaluation is indicated.
That's interesting, am I reading this right that the white eye was actually just because the optic disc was perfectly in view of the smartphone camera?
Yes - light reflecting off the nasal aspect of the retina. About 20 years ago, when our daughter was a toddler, we saw this on a series of digital photos (pre-smartphone). We were able to get an ophtho eval quickly, and it turned out to be benign - the combination of flash and the way she looked at the camera. As for the case you posted - social situation matters a lot.... we were able to get in quickly, but the parent and child you discussed got dismissed and delayed terribly.
Knowing the right things to say, how to access the system, and speaking the same language goes a long way.
Where can we find a link to anything about this case in the news?
I dont think there are any, I believe this is the only publication out there about it. It got sent to me anonymously.
There's no way this gets settled, right? I would imagine the defense knows that this case would be devastating to take in front of a jury but the family knows that too and is probably asking for an amount way beyond policy limits. But then again I guess there's no such thing as a guaranteed win when a jury can act in an unpredictable way.
I have no idea on this one... I'm not trying to sound flippant but its "just" blindness as opposed to a dead child, or a severely disabled child. Time will tell!
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