Gambling with Children 

Kaiser says its new hospital in Oakland offers first-rate services, but critics say the healthcare giant's decision to close pediatric care facilities in the East Bay has had grave consequences.

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Kristine Richter had worked in the Kaiser Hayward pediatrics acute care unit for most of her nursing career before she transferred to Kaiser's new San Leandro Medical Center. She explained that when the Hayward pediatrics unit was still open, a pediatrician was present at all times. "That's not how it would have been when we were there," Richter said, after hearing the account of what happened to Jenevieve and having received permission from the girl's parents to inspect the medical records from the night of the incident.

When the Kaiser Hayward pediatrics unit was open, the ER staff would have summoned the on-duty pediatrician to advise and assist in a severe case such as Jenevieve's, Richter said. "They are trained to see things that you don't often see in adults," she said of pediatricians.

But Jenevieve wasn't seen by a pediatrician until about twelve hours after she first arrived at Kaiser Hayward. Considering Jenevieve's young age and her severe symptoms, Richter said that, in her experience, the little girl would have been put in the pediatrics unit for observation after her first visit. "Not every patient that has a seizure gets admitted," she said. "But this was a six-month-old."

Bacterial meningitis works quickly. Once in the bloodstream, bacteria called Neisseria meningitides infects the lining of the brain and spinal cord, causing initial, "prodrome" symptoms, such as fever and nausea. In more developed stages, symptoms include seizures, severe rash, high-pitched cries, and neck stiffness. The Centers for Disease Control (CDC) website states — in bold type — that if meningococcal disease is suspected "It is important that treatment is started as soon as possible." Typically, a child receives antibiotics.

But the CDC also states that antibiotic treatment shouldn't begin until meningitis is highly suspected. Pediatric doctors and nurses usually make this determination with a "workup," which consists of a blood culture, a urine test, and a spinal tap. A spinal tap (or lumbar puncture) is a procedure during which a large needle punctures the spine and extracts spinal fluid. By testing spinal fluid for the appearance of the bacteria, a spinal tap generally provides quicker and more accurate results. But the procedure can be dangerous on infants, whose bodies are smaller and more fragile. While Jenevieve received both blood and urine tests, she did not get a spinal tap.

"There are risks with a spinal tap," Richter explained. "Pediatricians are more comfortable with the physical acts of doing it on smaller bodies." Before Kaiser Hayward's pediatrics unit closed, its pediatricians performed child spinal taps, Richter said. "I think pediatricians who are more used to giving babies spinal taps are more comfortable doing it," she said, "whereas adult doctors are less inclined to do a spinal tap."

Nurses suspect that Jenevieve did not receive a full workup because a pediatrician wasn't present to give one. "I don't have a crystal ball," Richter said, explaining further that it's impossible for anyone to know exactly what could have affected the outcome. "But I would hope — given her age, the febrile seizure, and past practices at our department — that when she came in the first time with the seizure, she would have at least been admitted for observation, had her workup finished, and given some antibiotics."

For their part, Kaiser officials say that the Hayward pediatrics unit, when it was still open, would not have admitted a child with Jenevieve's symptoms for observation. "The Hayward Medical Center inpatient pediatric unit ... never cared for, and would not have cared for, acutely ill patients such as an infant with bacterial meningitis," Barbara Crawford, Kaiser's Northern California vice president for Quality and Regulatory Services, wrote in an email to me.

Crawford added that Kaiser investigated Jenevieve's case and concluded that the girl's care was "appropriate and sound." She said that early symptoms of bacterial meningitis "mimic that of other, less serious illnesses" and are not easily detected at first. "This was the case with Jenevieve, who had no clinical signs of meningococcemia during her first visit to the emergency department," she wrote. "... As more symptoms emerged later in the day, Jenevieve was promptly transported to the Oakland Medical Center, where she could receive the higher level of care required for critically ill children."

But according to medical records, Jenevieve's treatment and subsequent transfer to Kaiser Oakland was not prompt. Within thirty minutes of her second arrival at the Kaiser Hayward emergency room, her vital signs indicated a serious problem. Her heart rate was 210 beats per minute and her temperature was 102 degrees — which are both indications of sepsis, a bodily inflammation that results from bacterial meningitis. According to her medical records, Jenevieve also had arrived at the Hayward emergency room with a dark rash, stiff neck, and high pitched screaming, which are also clear symptoms of bacterial meningitis.

At the Hayward facility, medical staffers consulted with the Oakland pediatric unit by phone on Jenevieve's case, and later sent photographs of her. But nurses say that even though it might have been too late to save the little girl during her second visit to the ER, Jenevieve's diagnosis was not made quickly enough, and that she should have been transported to Oakland much sooner. Hayward medical staffers waited two hours after Jenevieve arrived the second time before they called to transport the girl to Oakland, and then it took another two hours for the ambulance to arrive. "I felt like they were just patching her up while they were waiting for the transport to arrive," Dagatan said.

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